Provider Demographics
NPI:1790947778
Name:PEDIATRIC DENTAL CARE CENTER
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-627-6023
Mailing Address - Street 1:316 MARTIN LUTHER KING JR WAY STE 209
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4254
Mailing Address - Country:US
Mailing Address - Phone:253-627-6023
Mailing Address - Fax:253-627-4035
Practice Address - Street 1:316 MARTIN LUTHER KING JR WAY STE 209
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4254
Practice Address - Country:US
Practice Address - Phone:253-627-6023
Practice Address - Fax:253-627-4035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE059941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5000823Medicaid